1. Veterans’ Mental Health
Current Response to the Mandate & Challenges for the Future. Andy Bacon NHS England Central Team Lead for Armed Forces
March 2015

2. Cross Government Obligations Armed Forces Covenant/ Mandate
“The NHS need to demonstrating progress against the Government’s priorities of: upholding the Government’s obligations under the Armed Forces Covenant;
The Covenant says:
The Armed Forces Community should enjoy the same standard of, and access to, healthcare as that received by any other UK citizen in the area they live.
Personnel injured on operations should be treated in conditions which recognise service needs
For family members, primary healthcare may be provided by the MOD in some cases (e.g. when accompanying Service personnel posted overseas). And … should retain their relative position on any NHS waiting list, if moved around the UK due to the Service person being posted.
Veterans … should receive priority treatment where it relates to a condition which relates to .. their service, subject to clinical need
Those injured in service should be cared for in a way which reflects the Nation’s moral obligation …with professionals who have an understanding of Armed Forces culture

3. The Equalities Act
Access to services should be governed, as far as practicable, by the principle of equal access for equal clinical need. Individual patients or groups should not be unjustifiably advantaged or disadvantaged on the basis of age, gender, sexuality, race, religion, lifestyle, occupation, social position, financial status, family status (including responsibility for dependants), intellectual / cognitive function or physical functions.
Developing a better understanding of the unique needs of ex-service personnel and families enables discrimination based on need (and hence treated as a “Minority” with particular health needs).

4. DIVIDED RESPONSIBILITIES for Commissioning
Serving
Veteran
Operational Care
MoD/DMS
Not Applicable
Occupational Health
Public Health
(Immz and Screen)
(Health Promotion)
NHS England (PH)
Local Authorities
Primary Health Care
NHS England (Primary Care)
Community Health Care
NHS England (AF)
NHS CCG
Rehabilitation
Acute Hospital Care
Mental Health
Social care/Welfare
Charities/ Local Authorities
Specialised Health Care
NHS England (Spec Comm)

5. Armed Forces commissioning responsibilities
Serving Armed Forces in England
Serving Armed Forces overseas
Armed Forces Families registered with DMS med centres in England
Armed Forces Families registered with DMS med centres overseas
Armed Forces Families registered with NHS GP Practices
Reservists while mobilised i
Veterans (inc. reservists when not mobilised)
Primary Care
DMS ii
DMS
NHS England
&
NHS England iv
Community Mental Health
CCGs
Secondary acute & community care
CCGs iii
MOD Enhanced pathways
N/A
i - Reservists have access to DMS care whilst mobilised
ii - Serving personnel can access local GPs on an emergency basis if needing to access care whilst away from the military address
iii - The NHS England will commission specialised services for veterans, e.g. limb prostheses,
iv - While overseas, serving personnel and families can access DMS-commissioned healthcare where such provision exists, or may be provided with non-DMS healthcare by local Host Nation or other contracted arrangements, or have right of return for NHS care in England

6. NHS England - Armed Forces Health
NOT UK WIDE
NHS England - Armed Forces Health
NHS England Board
NATIONAL
LOCAL
NHS England Commissioning Operations
CLINICAL COMMISSIONING
GROUPS
Limited Range of Services
Reservists, Veterans’ & Families Commissioning
Armed Forces Commissioning
Design Principles :
Retain: Knowledge, expertise, capability, continuity, skillsets, credibility
Ensure: Momentum, partnerships, linkages, AFNs, practical configuration and delivery
Central & Regional Team
Community and Acute Hospital
for those registered in MOD Centres
Assurance of CCGs
All non-specialised services for Veterans, Families, Reservists
Health and Wellbeing Boards, AFNs, Community Covenant and partnerships
Armed Forces Commissioning
Interface between MOD and Providers
Veterans’ and families commissioning
Transition management
Veterans, reservists and families

7. TRANSITION IN AND OUT OF SERVICE
Transition – Wounded Injured and Sick; ‘service leavers’, mobilisation and demobilisation
CCGs
Reservists
Veterans
Families
DMS
Operations
Occupational
Primary
Mental
Rehab
NHS England
Community Care
Acute Care, CHC
TRANSITION IN AND OUT OF SERVICE

8. System and network complexity

9. Armed Forces Networks NHS Health Care Armed Charities Forces
Represent all local Stakeholders, including:
Regional Armed Forces command and health structures
MoD Personnel Recovery Units
Local NHS – commissioners and providers
Local Authorities
Charities
Veterans and families organisations/ individuals – patient and user voice
Supporting Transition of service leavers, local learning, national learning, information sharing, commissioning and key patient voice issues
Meet regularly 3-4 times per annum and ‘virtually’ all the time to resolve cross-system issues
Currently 9 in England mapped closely to Army regional Brigade structure
Routine monthly AFN teleconf - to share system leadership and oversight of issues with partners and stakeholders
Regional models vary to reflect stakeholders and relationships, but based on core principles above
NHS
Health Care
Armed
Forces
Charities
Local Authorities

10. What we know? Who are our community?
Age, service history, type of service
When do they engage?
Delay
Who do they engage through?
Where do they engage?
Veterans distribution
What are their issues?
Co-morbidities
New reports:
Ashcroft – most do well from service
Stephen Phillips – (Former Members of the Armed Forces and the Criminal Justice System)
RBL – (UK Household Survey of the Ex-Service Community)
KCL – “Myth buster”
Service evaluations (NVMHN, CIE Needs Assessments)
Etc.

12. OP and Community Veteran Provision (IAPT and NVMHN for NHS)

13. OP and Community Veteran Provision by Region

14. Early Impressions from Review of Needs Assessment
Local Authority JSNAs
Good (but not complete) coverage
Narrow focus of assessments
CCG provision:
IAPT/ Parity of Esteem/Crisis Concordat/ Closing the Gap
Variable specialist veteran provision:
Type of services
Availability of services
Diverse Charity Provision
A few large vs. multiple small;
Quality assurance & navigation issues
Gaps
National gaps e.g. crisis, young people, etc.
Limited user views
Families
Step 3
Co-morbidities

15. NHS England’s General Roles in Mental Health
Direct Commissioning for
Health and Justice settings
Specialised (e.g. Forensic, Tier 4 CAMHs)
Delivering National Programmes:
The Mental Health Crisis Care Concordat
The right quality of treatment and care when in crisis
Recovery and staying well, and preventing future crisis
Parity of Esteem
Better data and information for the public, commissioners and providers
Addressing the physical health of people with serious mental illnesses
Addressing and improving crisis care
Closing the Gap
Mental health must have equal priority with Physical Health
Involvement of many partners from across the voluntary sector, from national charities like Combat Stress and Help for Heroes, to local community groups
CCG Assurance …..

16. Current NHS Roles re Veterans MH
CCGs (should have) taken over veterans commissioning
IAPT services
Different local models to meet local needs
Veterans are below “critical mass”
NHS England inherited roles:
£1.5M nationally for Regional (locally decided to deliver Murrision “Fighting Fit”) - original purpose more professionals
£3.2M specialised in Patient PTSD
£350k Big White Wall
Developing the Evidence Base
Domestic Abuse
Needs assessments
Pilot development

17. Other Activity in Veterans’ Mental Health
Providing fora for advocacy and discussions:
Clinical Reference Group
Veterans’ Mental Health Network
Armed Forces Networks
Covenant promotion e.g. contract, royal colleges etc.
Funding
Response to national reports:
House of Commons Defence Select Committee
Philips on Veterans in Custody
Improving integration and transition:
Temporary Registration
Summary of care record on discharge

18. Changes in the last 2 years
Transferred Service personnel from MoD system to NHS System and so single registration (MoD retain own record)
Maintained continuity of intherited mental health services for Veterans
Rewrite of Joint Services Publication for joint work with the recovery of the wounded, injured and sick and transition
Research in Domestic Violence,
Needs assessments for veterans: Mental Health (in progress)
Gathering of data on activity of 10 regional mental health services.
DCMH & NHS Provider Pilots
National IAPT data capture and Health and Justice capture including L&D

19. Possible Future Roles
Use System Management/ Market Management to deliver new services to:
Improve Data capture
Define roles more clearly
CCG
Charities
NHS England (redefined specialist only?)
Provider assurance
Promote under provided services:
Complex Trauma with comorbidity
Personality/Adjustment Disorder
Families support

20. Possible Items for Discussion
PREVENTION
Importance of transition out of service work between DMS and NHS
Understanding incidence and causes of:
Alcohol misuse
Mental ill health
Criminal behaviour (especially violence and sexual)
ACCESS
Who is a veteran?
Attribution a minimal issue in healthcare access
Behavioural aspects of care:
Accessing care
Non clinical interventions
INTEGRATION
Common Philosophy
Data definitions
Common assessment
Common Pathways
Record sharing
Measuring joint outcomes

21. Thank you! andy.bacon@nhs.net
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